The Myth of Improved Quality in Nursing Home Care: Setting the Record Straight Again

April 17, 2014

April 17, 2014

A recent report by the Department of Health and Human Services' Inspector General found that one third-of nursing home residents in a Medicare-nursing home stay suffered an adverse event or other harm in August 2011 and that most of the events were preventable and caused by problems in staffing.[1] Yet the nursing home industry claims that nursing home quality of care has improved. The Center for Medicare Advocacy has written about this issue before,[2] but in light of the industry's insistence – despite clear evidence to the contrary – that care for residents is improving, it is time to set the record straight again.

Industry Claims

In its 2013 Quality Report,[3] the American Health Care Association (AHCA), the trade association of for-profit providers and multi-state chains, reports that quality of care in nursing facilities is improving. Among other evidence, AHCA cites improvements in almost all of the quality measures from 2011 to 2012 and higher star ratings in the Centers for Medicare & Medicaid Services' (CMS's) Five-Star Quality Rating System.[4] AHCA reports that between 2009 and 2013, the proportion of five star facilities increased from 11.8% to 19.6% and the proportion of one-star facilities decreased from 22.5% to 13.5%.[5]

Improved Star Ratings Do Not Necessarily Demonstrate Improved Quality of Care for Residents

Improvements in facilities' star ratings do not necessarily reflect improvement in residents' quality of care and quality of life. Rather, they likely reflect facilities' self-reported and unaudited claims that staffing and quality measures have improved. As discussed below, Abt Associates – a CMS contractor – analyzed the first three years of the Five-Star Quality Rating System. They noted that, by design, the health survey measure remained constant over the three years and that improved overall ratings may "reflect changes in reporting practices rather than real changes in quality."[6]

Nursing Home Compare

Since the Clinton Administration, the federal government has maintained a website called Nursing Home Compare[7] that provides information to the public about nursing facilities that participate in the Medicare and Medicaid programs. Over the years, both the type and the amount of information available on Nursing Home Compare have increased significantly. CMS uses the website to post information reflecting state survey results and, as reported by the facilities themselves, staffing levels and quality measures (QMs). The website also reports federal sanctions that CMS imposes against facilities that are cited with deficiencies for violating federal standards of care. Sanctions imposed under state licensing laws, however, are not included in Nursing Home Compare.

Since 2008, CMS has rated facilities separately on each of three domains – health inspections, staffing, and quality measures – and on an overall or composite measure that combines the three individual measures. In calculating the overall measure, CMS begins with the survey measure, which it may increase or decrease by one star in either direction, based on very high or very low star ratings in the self-reported staffing levels or self-reported QMs, or both. As a result, facilities' higher composite ratings reflect facilities' self-reported data on staffing and QMs.

Health Inspections

Nursing facilities that participate in the Medicare or Medicaid programs, or both, have an unannounced survey each year. Surveys are conducted by state survey agencies, usually located in the state department of health, using a survey protocol that has been developed, tested, and validated by the federal government.[8] Although the Government Accountability Office has issued many reports over the past 15 years describing the federal enforcement system as under-citing deficiencies and under-coding the significance (scope and severity) of deficiencies it identifies, the publicly-conducted survey is the only objective, independent evaluation of the quality of care provided by nursing facilities.

The health inspection domain in the Five Star Quality Rating System is based on the results of annual and complaint surveys conducted over a three-year period, with more recent data weighted more heavily.[9] The top 10% of facilities in a state receive five stars; the bottom 20%, one star; and the middle 70%, two, three, or four stars (23.33% each). One star, the lowest score, is defined as "much below average," and five stars, the highest score, defined as "much above average." CMS has used this scoring mechanism since the Five Star Quality Rating System was first introduced in 2008. "The distribution of ratings for health inspections is essentially fixed."[10]

Quality Measures

On Nursing Home Compare, CMS publicly reports 18 different quality measures, which are derived from resident assessments conducted by the facilities themselves and electronically submitted to CMS. Nine of the 18 measures are included in the rating system for the QM domain.[11]

CMS assigns stars in quality measures, using resident assessment information that facilities report to CMS, although CMS does not "formally check" the assessment information "to ensure accuracy" for purposes of this measure.[12] CMS's rating system for QMs is extremely complex: three of the nine measures (catheter, the long-stay pain measure, and short-stay pressure ulcers) are risk-adjusted; eight measures use national data (only one measure, activities of daily living for long-stay residents, uses state-level data); CMS has rules and imputation rules for missing data; and CMS assigns point thresholds for each star category.[13] Half of the 18 measures are not used at all in calculating the publicly-reported QMs. Significantly, unlike health inspections, where the distribution of ratings is fixed and remains constant, the distribution of ratings for QMs is "allowed to shift."[14]

The accuracy of QM information is a matter of concern to CMS, which, in August 2013, directed facilities to complete and submit by September 30, 2013 updated information on missing discharge assessments. CMS reported that facilities' late submission or non-submission of data on discharges affects "QM data integrity."[15]

Since health survey ratings have remained constant, while both staffing and QMs are "allowed to shift,"[16] facilities' changing star ratings reflect improved ratings in the self-reported staffing and quality measures.[17]Neither the staffing data nor the assessment data that lead to the QMs are audited by CMS for purposes of public reporting.

Abt Associates' analysis of the first three years of the Five-Star Quality Reporting System found that improved overall ratings were the result of improvements reported by facilities in staffing and QMs and may "reflect changes in reporting practices rather than real changes in quality"[18]:

Reflecting the improvements in QM and staffing ratings, there were also improvements in overall quality ratings during the three years examined. In January 2009, 22.7 percent of facilities had a one-star rating while 35.2 percent had a four- or five-star rating. By December 2011, the proportion with a one-star rating had declined to 15.6 percent, while 43.2 percent had a rating of four or five stars.[19]

The Center for Medicare Advocacy's Analyses Have Shown that Poor Quality Facilities Report High Staffing and QMs, Boosting Their Overall Star Ratings

In September 2013, the Center showed that facilities with one star in health surveys nevertheless report high quality measures.[20] Specifically, the Center found that facilities with one-star ratings in health surveys in three geographically diverse states – Georgia, Illinois, and Oregon – had high quality measures. In Georgia, 29 of 57 one-star facilities (51%) had four stars in quality measures; in Illinois, 33 of 93 one-star facilities (35%) had four stars in quality measures; and in Oregon, two of five facilities (40%) had four stars in quality measures.

The Center found similar results with Special Focus Facilities (SFFs),[21] facilities that are identified by CMS as among those providing the worst care in the country.[22] CMS requires that survey agencies conduct additional surveys in SFFs and that more intensive enforcement actions be imposed against SFFs. The Center's analysis of SFFs found that 17 of 47 facilities added to the SFF list (36%), as of May 16, 2011, reported quality measures leading to four- and five-star ratings in the QM domain.

On April 15, 2014, the Center did another analysis of the facilities on the SFF list, this time, looking at facilities that had not improved, as of March 20, 2014. The analysis shows similar disparities between the overall measure, the health survey measure, staffing, and the QMs.[23]

Nineteen facilities were identified on the list of Special Focus Facilites that had not improved; they had been on the list for 12 to 40 months.

11 of the 19 (58%) had overall ratings that exceeded their health survey

9 of the 19 (47%) had overall ratings of 2 stars, but health surveys of 1 star

Staffing measure

1 of the 19 (5%) had 5 stars in staffing

10 of 19 (53%) had 4 stars in staffing

3 of 19 (16%) had 3 stars in staffing

2 of 19 (10%) had 2 stars in staffing

2 of 19 (10%) had 1 star in staffing

1 of 19 (5%) had staffing not reported

Quality measures

1 of 19 (5%) had 5 stars in QMs

9 of 19 (47% ) had 4 stars in QMs

7 of 19 (37%) had 3 stars in QMs

1 of 19 (5%) had 2 stars in QMs

1 of 19 (5%) had 1 star in QM

A recent example of a Special Focus Facility in Texas clearly illustrates the point that poor facilities can report high quality measures and improve their overall star rating as a result. Southaven Nursing Center, a Dallas nursing facility, lost its Medicare and Medicaid certification in March 2014, following 39 months on CMS's SFF list. The facility received two stars in health inspections, but five stars in QMs, boosting its overall rating to three stars.

Conclusion

The Inspector General found that nearly one-third of Medicare residents experienced very poor care in August 2011, much of which it considered avoidable and attributable to inadequate staffing. Industry claims of improving care are based primarily on improvements in self-reported data and are highly suspect.